Following our roundtable event on emergency care for children and young people, Dr Rakhee Shah (@shahrakhee), a research associate at the Association for Young People’s Health (@AYPHcharity) and Paediatric Specialty Registrar in London, reflects on the issues raised concerning young people’s mental health.
The recent QualityWatch report on emergency hospital care for children and young people outlined how young people’s use of emergency care has changed over ten years. Overall there has been a 6% increase in hospital emergency admission rates across all children between 2006/7 and 2015/16. However it is important to note that the number of emergency admissions amongst 10-19 year olds actually dropped during the ten year period, indicating that the increase in emergency admissions by children are attributable to the under 10s. Whilst we need to better understand the increase in admissions for children there are also trends that need further exploration for young people. The most notable is that the older age group showed some increases in admissions associated with specific conditions such as abdominal pain and poisoning.
Strikingly, there was a 27% increase in re-admission to hospital within 30 days amongst children and young people admitted for poisoning by other medications and drugs, which is more prevalent in the 10-24 age group. These figures indicate that we may be failing to provide our young people with adequate mental health treatment prior to discharge and, more importantly, failing to provide ongoing support in the community.
The question is why are we failing this particular group? It is clear that one of the reasons is that the clinical thresholds to receive statutory child and adolescent mental health services (CAMHS) are high. It is approximated that the prevalence of mental health problems in young people aged 16-25 is 10%, yet analysis from the Adult Psychiatric Morbidity Survey shows that even in those that have severe mental health problems, almost half (46%) were not receiving mental health care.
Second, there is evidence to show that the prevalence of mental health problems such as common mental disorders and self-harm are on the rise, particularly in young women aged 16-24 who have emerged as a high-risk group.
Third, there have been cuts to government-funded early intervention programmes including positive activities for young people, and services for teenage pregnancy, alcohol and drug use, which may be contributing to young people having more severe mental health problems.
In the long term we need to focus on preventing the ‘upstream factors’ that contribute towards mental health problems, which include investing in resilience training in schools, providing access to high-quality education and health services, and decreasing deprivation. We need to ensure that early support services are in place for young people who are identified as being at risk of developing mental health problems, for example for young people presenting with stress and emotional difficulties. These early intervention services will help prevent mental health problems developing in the long term.
Helping today’s patients
However, what needs to be done to help our young people who are currently experiencing mental health problems? There was consensus at the Nuffield Trust roundtable discussion that to reduce the readmission rate amongst children and young people following self-harm would require a whole system approach. It is important to up-skill people who engage with young people on a regular basis such as teachers, school nurses, youth workers, general practitioners, paediatricians, doctors in A&E, and others. These practitioners need to recognise, risk assess and refer young people to mental health services at an earlier stage, which may in the long term reduce the severity of mental health conditions presenting to A&E.
Young people and their parents should be provided with an option to self-refer to a triage service that can assess the severity of the condition and signpost young people to appropriate mental health services. Both young people and parents, if given the option, may present to mental health services earlier prior to symptoms escalating, and be treated more appropriately in the community, reducing A&E attendances.
We must not forget the key role that parents play in supporting and contributing towards successful outcomes for young people with mental health problems. Enabling parents to become part of the solution includes developing parent support groups, developing services where parents can receive more practical advice about how to manage crises to prevent escalation requiring hospitalisation, and providing parents with liaison staff or a case-worker who can guide them on where to get further help.
Child and adolescent mental health services (CAMHS) are stretched and the service requires an increased workforce to meet the increasing demand in order to be able to review discharged patients in a timely manner.
One idea debated at the roundtable event was whether changing CAMHS contracts from block to outcomes based payments could potentially incentivise improvements in mental health outcomes for young people. Currently, the majority of CAMHS services are under block contracts, which means that payments are made in advance on a regular basis to provide child and adolescent mental health services both in acute and community settings. Payments are independent of the actual number of patients treated or activity levels, but can be varied based on patient need or historical expenditure.
Although block contracts are predictable, flexible (as payments are not related to one particular activity) and have low transaction costs, they have been criticised for a lack of accountability and transparency. Payment by results (PbR) or outcomes based payments are used by the government to fund child health services in the acute sector and NHS England have stated that they want to move towards evidence-based, outcome-focused improvements in mental health services working in collaboration with children, young people and their families. A consideration of the advantages and disadvantages of this approach is important as we move forward. Those present at the roundtable discussion felt there was potential for an outcomes based payment system to support innovation and introduce new models of care that respond to young people’s needs. It was also recognised that outcomes of CAMHS services are influenced by a complexity of factors and that this also needs to be taken into consideration.
Voluntary sector role
More recently, the emerging role of social prescribing and voluntary organisations in improving outcomes for young people with mental ill-health has come into the spotlight, as research shows that mental health problems can be caused by social and environmental factors. Social prescribing and support services provided by non-medical organisations can play a key role in providing early interventions for young people and their families at risk of developing mental health problems.
Development of new models of mental health care are key to improving mental health outcomes and reducing readmissions to hospital following self-harm for young people, but it is important to ensure young people’s views are at central, enabling services to be more accessible and age-appropriate. Young people, when consulted during a social prescribing project for emotional health and wellbeing in Rochdale, suggested the best forms of emotional support could include a telephone service where they can speak to people, video consultations and informal support signposting to other services. Increased awareness about local non–medical sources of support within the community amongst healthcare professionals, teachers and youth workers is required to appropriately signpost young people with stress and emotional difficulties.
In order to improve young people’s mental health outcomes, in view of limited resources with financial cuts being made in the NHS and other services, now is the time to stop working in silos and come together (government funded sectors and voluntary organisations) to provide strong leadership and advocate at a national level for more investment in whole community approaches.